Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 44.
Instituted on : 24.01.2019.
Decided on : 15.11.2021.
Nikhil Arya, aged 32 years, resident of 275, Old Housing Board Colony, Rohtak, presently resident at Omaxe City, District Rohtak.
………..Complainant.
Vs.
Star Health and Allied Insurance Company Ltd., through its Branch Manager, Ashoka Plaza, 3rd Floor Delhi Road, Rohtak.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
Present: Shri Sameer Gambhir, Advocate for the complainant.
Shri Gulshan Chawla, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
Brief facts of the case are that the complainant had availed the Medi Claim Insurance Policy bearing No.P/211118/01/2018/003168 and Policy period from 14.10.2017 to 13.10.2018 of Family Health Optima Insurance 2017. On 14.3.2018, the complainant was admitted at Avantika Multi Specialty Hospital, New Delhi for treatment of Typhoid Fever with acute gastroenteritis and intimation was given to the respondent Insurance Company, vide claim no. CLI/2018/211118/0650137 for seeking reimbursement of hospitalization expenses. The complainant had submitted the treatment record and medical expenses record of about Rs.70,000/- to the respondent Insurance Company for getting reimbursement of claim amount. The respondent Insurance Company vide letter dated 4.5.2018 without examination and verification report from hospital submitted that indoor case records of the Avantika Multi Speciality Hospital New Delhi that tampering is noted in the temperature records. The respondent insurance company has verified from the Hospital regarding treatment of complainant and found genuine and after that repudiation by alleging tampering in temperature is wrong and baseless. Further, the Avantika Multi Speciality Hospital New Delhi has not denied regarding admission, treatment of Enteric fever/Typhoid fever with gastroenteritis, so it is wrong to allege in letter dated 04.05.2018 without examination and verification from Avantika Multi Speciality Hospital New Delhi that tampering is noted in temperature records. The respondent Insurance Company has verified from the Hospital regarding treatment of complainant and found genuine and after that repudiation by alleging tampering in temperature is wrong and baseless. Complainant was suffering from Typhod fever(enteric fever) with gastroenteritis(stomach disorder, pain, vomiting etc.,). The respondent Insurance Company has not paid the claim amount of Medi Claim Policy to the complainant. Hence there is deficiency in service on the part of respondent. Hence, this complaint and the complainant has prayed for directing the opposite party to pay an amount of Rs.70,000/- for Medi Claim reimbursement amount on account of Hospitalization Expenses for treatment alongwith interest @ 18% p.a. from the date of hospitalization i.e. 14.3.2018 and also to pay an amount of Rs.15,000/- on account of harassment and deficiency in service to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that application form was received in the office of respondent, wherein complainant opted for Family Health Optima Insurance Plan and respondent replying upon the contents of the proposal form to be true, issued the policy bearing policy no.P/211118/01/2018/003168 for the period 14.10.2017 to 13.10.2018 covering Nikhil Arya-Self, Shipla-Spouse for the insured limit for Rs.5,00,000/-. The policy in question was issued only on the basis of declaration given by the complainant in the proposal form, subject to terms and conditions were correct. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to be complainant alongwith the policy schedule. It is also submitted that the policy was contractual in nature and the claims arising therein was subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and basis fully aware of such terms and conditions and executed the proposal form. It is also submitted that on the receipt of claim intimation, respondent registered the claim of the complainant and allotted the claim number CLI/2018/211118/0650137 for better communication in regard to the present claim. It is wrong and denied that the complainant has spent an amount of Rs.70,000/- on the treatment, as alleged. The complainant had submitted the claim form with the respondent for the claim disbursement of an amount of Rs.52,519/-. On getting the claim intimation, the claim of the complainant was investigated and it was found that in the Indoor case records of the above hospital, tampering is noted in the temperature records. The temperature is within limit. Thus, the claim was repudiated and the same was informed to the insured vide letter dated 3.5.2018. Hence, there is no deficiency in service on the part of respondent. It is prayed that complaint may kindly be dismissed with costs.
3. Ld. Counsel for the complainant has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C2 and closed his evidence on dated 3.3.2020. On the other hand, ld. Counsel for the opposite party has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R12 and closed his evidence on dated 4.1.2021.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the opposite party vide letter dated 03.05.2018 on the ground that : “We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of enteric fever with acute gastroenteritis(AGE). It is observed from the indoor case records of the above hospital that tampering is noted in the temperature records. Our medical team is of the opinion that the hospitalization of the insured patient is not warranted for the above diagnosis. We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim”. A bare perusal of the discharge summary placed on record mentioned in Ex.R9 i.e. History itself shows that : “Patient got admitted with c/o High grade fever with chills x 5 days associated with recurrent vomiting, loss of appetite, gen. weakness, Burning sensation while urination, body ache & abd. Pain. No h/o any chronic major illness”. Meaning thereby, the complainant was admitted in the hospital as an indoor patient. Hence the claim of the complainant has been wrongly repudiated by the opposite party. As per complainant, he has demanded an amount of Rs.70000/- for mediclaim reimbursement amount on account of hospitalization expenses. Whereas as per written statement, affidavit and assessment report Ex.R11 filed by the opposite party, opposite party has assessed the liability of Rs.51427/-.
6. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay Rs.51427/-(Rupees fifty one thousand four hundred and twenty seven only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 24.01.2019 till its realization and shall also pay a sum of Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
15.11.2021.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
